Borderline personality disorder (BPD) is frequently encountered in a variety of clinical settings.1 On inpatient units, it is estimated that 20% of patients have comorbidity with BPD. In outpatient clinics, 11% of patients meet diagnostic criteria for BPD. Despite these statistics, BPD has neither the same level of public awareness nor the same level of research funding that other major psychiatric diagnoses have.

The American psychoanalyst Adolph Stern was the first to use the term “borderline” in describing a group of patients who had both neurotic and psychotic features.2 He considered these patients to be in the “border line group.” It was not until 1949, however, that the term was applied to children. Margaret Mahler used the term “borderline” to describe a group of children who displayed “low frustration tolerance, poor emotional differentiation from their mothers, and [who were] beset by a series of neurotic-like defenses.”

Since Stern, the amount of research on BPD in adults has grown exponentially. Research on BPD in children and adolescents has not kept pace despite increasingly strong evidence of developmental antecedents for the condition in adult BPD.

Although an extensive historical review of the diagnosis of BPD in children and adolescents would be interesting, it is beyond the scope of this article. However, it is increasingly clear that BPD progresses from a strict psychodynamically based construct to a neurodevelopmental disorder with roots in the genetics of the child, the child’s temperament, and the environment. BPD is marked by skills deficits in broad areas of developmental ability, including deficits in emotion regulation, distress tolerance, and interpersonal functioning.

Waiting for therapy

Although symptoms typically begin in adolescence, there has been a strong reluctance in the psychiatric community to diagnose BPD in anyone younger than 18. Even in adults with BPD, it remains a highly stigmatized disorder among physicians and mental health professionals.3 Although DSM clearly allows for the diagnosis to be made in patients who have had enduring symptoms for more than a year, clinicians tend to write “deferred” on Axis II, even when an adolescent meets sufficient diagnostic criteria. What this means is that in many adolescents, mood and other behavioral and psychiatric disorders are diagnosed, and often medication is prescribed for symptoms even when clinical criteria for disorders other than BPD are not met.

Because of the reluctance to make the diagnosis, BPD has been underrecognized and underdiagnosed in adolescents and, as a consequence, has not been adequately studied. As such, its nature and course in adolescent populations are not well understood. Equally troubling is that studies show that treatment typically begins in early adulthood.4 It appears that from the onset of symptoms to the definitive diagnosis of BPD, treatment can lag for many years. The lack of early treatment can mean years of suffering and years of practicing maladaptive (although temporarily effective) and self-reinforcing behaviors (eg, self-injury for emotional regulation).

Evidence suggests that BPD can be reliably diagnosed in adolescents5; however, other studies show that the diagnosis is not always stable over the course of development. For instance, a prospective study undertaken by Chanen and colleagues6 found that only 40% of adolescents aged 15 to 18 with BPD met criteria for the disorder at 2-year follow-up.

A community study looked at self-reported symptoms at 2- to 3-year intervals starting in early adolescence (age 14) and ending in early adulthood (age 24) in adolescent twins with BPD. The results showed a decrease in rates of the diagnosis over the study period, with significant reductions in symptoms at each study interval during the 10-year follow-up.7

What is already known about borderline personality disorder (BPD) in children and adolescents?

? BPD in adolescents has been a controversial diagnosis. Research indicates that the presentation in adolescents is very similar to that in adults.

What new information does this article provide?

? DSM does not prohibit the diagnosis of BPD before age 18. The earlier the diagnosis, the earlier an empirically validated treatment can be applied. Furthermore, BPD may not be a lifelong condition.

What are the implications for psychiatric practice?

? Adolescents overwhelmingly find the diagnosis to be validating of their experience. An early diagnosis can mean an earlier targeted intervention that will help avoid multiple and unnecessary medication trials and adverse effects.

Another study looked at 407 adolescents with cluster B symptoms.8 The findings show that BPD and other cluster B symptoms tended to persist even when formal diagnostic criteria for cluster B on Axis II were no longer met.